Inspection on 08/11/06 for Mereside

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mereside 24/10/07

Mereside 10/03/06

Mereside 08/09/05

Mereside 16/03/05

Mereside 13/10/04

Mereside 17/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mereside 42 St Bernard`s Road Olton Solihull West Midlands B92 7BB Lead Inspector Kerry Coulter Unannounced Inspection 8th November 2006 09:30 Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mereside Address 42 St Bernard`s Road Olton Solihull West Midlands B92 7BB 0121 707 6760 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Tom Eyton Mr Tom Eyton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May also provide care, subject to appropriate and ongoing assessment, to people with a Learning Disability over 65 years of age. 10th March 2006 Date of last inspection Brief Description of the Service: Mereside is a privately owned Care Home, for adults with learning disabilities. The owner is also the registered care manager. The Home, which opened in 1986, is registered to provide accommodation, board and support for up to 15 adults. Some of the service users have severe learning disabilities with challenging behaviour and profound communication difficulties. The lack of a vertical lift combined with steep steps to the second floor makes the Home unsuitable for very frail or people with a physical disability. The Home, which blends in with its surroundings, is located in a residential area and easily accessible by public transport. Local amenities such as GPs surgeries, churches and a grocery shop are within walking distance. The Home is approximately three miles from the centre of Solihull. The fees charged to each service user range from £430 to £750 per week. Service users also pay for their toiletries, hairdressing, visits to restaurants, magazines and holidays. The CSCI inspection report is available in the home for visitors to read if they wish to. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector over a period of seven and a half hours from 9:30 am – 5 pm. A pre-inspection questionnaire was received from the service and written feedback from four service users which was helpful and forms part of the information in this report. There was an inspection of the whole of the physical environment. All service users were seen and time was spent in communication with them both separately and together. Observations of interactions and communication methods between service users and staff were important due to the limited verbal communication skills of some service users. Service users’ care plans, risk assessments and a number of Health and Safety records were inspected. What the service does well: The home had a relaxed atmosphere. 75 of staff have achieved an NVQ, this exceeds the standard that at least 50 of staff have achieved this. Staff know the service users well, what they like and don’t like and how they want staff to support them. Prospective new service users have opportunities to visit the home before making a decision to move there. Staff have the information they need in individuals care plans so that they know how to support the person to meet their needs and achieve their goals. Service users are supported by staff to maintain contact with relatives and friends. Meals are varied and at a time to suit service users. Staff eat with service users creating a friendly and chatty atmosphere. Service users have regular health checks and other health professionals are involved in residents care so that they get the healthcare that they need. Service users are made aware of the complaints procedure. Service users are often asked what they think of the home and how it could be better. The home had a visit from the Environmental Health Officer in January 2006, the findings were that the home had a good standard of hygiene. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Risk assessments have been completed for a wide variety of activities that could pose a risk but some improvement is needed to ensure all risks are fully assessed to promote service users safety. It was not clear that service users are always protected from the risk of abuse or harm. Some service users have made allegations against other service users, others have been hit by service users. Improvement is needed to ensure such incidents are dealt with under adult protection procedures to ensure service users are safe from harm. Sometimes service users monies is not appropriately spent. The home does not have a policy in place guiding staff on the use of service users monies, one needs to be developed to ensure service users finances are fully safeguarded from the risk of abuse. Access to the laundry needs to be reviewed so that staff and service users do not have to go outside in the cold weather and feel comfortable accessing this area. The Manager will need to ensure additional training is arranged for those staff who missed the challenging behaviour training so that they are fully able to respond and manage incidents of challenging behaviour. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provide prospective service users with relevant information about the home to enable them to make a choice about if they want to live there. The home undertakes assessments of service users to ensure they are suitable for the home, or that their needs can be met. EVIDENCE: There is a Statement of Purpose and Service Users Guide which are available in the home for service users and visitors. The Service Users Guide is pictorial and assists with interpretation for some residents. Both documents are comprehensive and provide all required information to make a choice about the home and give an accurate picture of care provision and the level of service. Since the last inspection a new service user has been admitted to the home. It was good that despite the fact they had previously lived at the home on a temporary basis a full assessment had been undertaken prior to them moving in, to ensure the home was still able to meet their needs. Records and discussion with staff show that introductory visits were made to the home over a seven week period and the resident was then consulted about if they wanted to move in. The Manager said that a three month review meeting had taken place to confirm if the placement was to become permanent. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have the information they need in individuals care plans so that they know how to support the person to meet their needs and achieve their goals. Service users make decisions about their day-to-day lives with assistance if needed and are consulted on what goes on in the home. Service users are supported to take responsible risks but written assessments need to be available for all identified risks to ensure the safety of service users. EVIDENCE: The previous inspection indicated that work was needed and ongoing in updating and improving the quality of information and content of care plans. At this inspection the care plans for three service users were sampled. A plan was available for each individual. The care plans included how staff were to support the service user to meet their needs. These included mobility, social and leisure, behaviour, daily living skills, family contact, communication, choice, privacy, dignity, rights, independence, fulfilment, health and self-care. Goals had been set as part of the care plan. Care plans had been regularly reviewed. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 11 Examples were seen during the inspection of service users making choices about daily routines – what food to eat, spending time in their room, activity in the home etc. Service users said ‘I get a choice of meals’, ‘I can choose what time I eat’. Staff were positive and responsive where service users clearly wished to take particular actions. Service users views are sought via regular service user meetings. Issues discussed include fire procedures, activities, holidays and complaints. Service users also have the opportunity to complete a questionnaire about their views of the home on an annual basis. As previously required agreements are now in place regarding service user contributions towards the home vehicle, these have been signed by the service user or their relative. There is evidence that service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. Risk assessments sampled had all been reviewed. It is an improvement that since the last inspection a log of risk assessment in place has been completed, this makes it easier to access the assessments. Risk assessments have been completed for a wide variety of activities that could pose a risk but some improvement is needed to ensure all risks are fully assessed. Assessment information for one service user recorded some areas of risk, both to him and others. This included previous incidents of using knives, glassware and possible risks to children. Risk assessments to assess the current level of risk and control measures in place were not available. Discussion with the Manager and Deputy Manager indicated they had not completed an assessment as they felt there was no longer a risk. Risk assessments for service users who have a history of allegation making also need further development to protect both the service user and members of staff. Fire evacuation risk assessments completed were of a good standard. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that the people living in the home experience a meaningful lifestyle. Service users are offered a healthy diet and enjoy their meals. EVIDENCE: The home provides opportunities for the development of social and personal skills. Service users are involved in the usual range of domestic activity: cleaning bedrooms, shopping, preparing food/drinks, taking clothes to the laundry. Promoting personal hygiene is also an important part of this development. Varying levels of skill or risk are mirrored with the required level of staff support. Activity records were sampled for three service users. These showed varied and suitable activities are offered to include shopping, pub lunches, beauty sessions, foot spa’s, parties and BBQ’s. Some service users attend the day centre or college. One goes to a placement at a farm, he said he enjoyed this. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 13 Another service user said that there were enough activities on offer and that he did not get bored. One service user was doing some artwork in her bedroom, she said she enjoyed this activity. It was nice that lots of her completed pictures were on display in the home. The recording of activities undertaken or offered has improved since the last inspection. It is good that part of the written record of activity includes a comment from service users about if they enjoyed the activity. This enables staff to review activities undertaken and offer activities that have previously been enjoyed. Service users are also consulted about the activities on offer at regular meetings. Opportunities are available to go on holiday, one service user has been to Spain this year supported by two staff. One staff spoken with commented that the Manager was intending to increase staffing levels at weekends so that more opportunities for activities could be provided. Care plans and daily records showed that contact with relatives is supported by staff. Staff recently organised a 20th anniversary party at the home to celebrate the home being open for 20 years. It was good that not only were relatives of current service users invited but previous service users and their relatives were also invited. Food provision was observed to be good. Sample menus were sent to the Commission prior to the inspection. It is good that care plans contained information about individual food preferences, this assists staff when planning menus to ensure food that service users like is on offer. Food records sampled were completed daily and showed that a varied diet is offered to include the recommended five portions of fruit and vegetables per day. Lunch time practice was observed, this was good. A choice of soup, sandwiches or both was on offer. Second helpings were available. Staff ate with service users creating a friendly and chatty atmosphere. Support was given as needed, for example one individual started to cough and was immediately given assistance by staff. Service users spoken with confirmed there was a choice of meals and also a choice of when you ate. Most service users have their evening meal quite early but one service user who prefers meals later confirmed they have the opportunity for this. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that service users generally receive personal support in the way they prefer and require and their health needs are met. The management of the medication protects service users. EVIDENCE: Care plans sampled detailed how staff are to support individuals to meet their personal care and health needs. Service users were observed to be dressed appropriately to their age, gender and the cold weather. One relative had commented in the homes quality assurance questionnaire that the ‘quality of care is excellent’. Health action plans have now been completed for all service users. This is a personal plan about what an individual needs to stay healthy and what healthcare services they need to use. Service users were referred to health professionals where appropriate. Service users had regular check ups with dentist, chiropodist and optician. Records of all appointments were kept including the outcome with any action that staff need to take to ensure the individuals health needs are met. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 15 Systems for administering medication to service users were in good order and ensure medication is safely administered. Staff have completed medication training, certificates were available to evidence this. A monthly audit of all non blistered medication supplies is undertaken by the Manager. The Medication Administration Records (MARS) were signed appropriately. These crossreferenced with the blister pack indicating that medication had been given as prescribed. Detailed protocols were in place for all as required (PRN) medication prescribed stating when, why and how much should be given to the individual. Records showed regular medication reviews take place to ensure service users are having the medication they need. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that service users know that their views are listened to and acted on. Satisfactory arrangements are not in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is discussed at service user meetings, service users are also consulted about any complaints they may have as part of the meeting. One service user spoken with said they had no complaints about the home but if they did they would tell staff. The Deputy Manager recently attended the CSCI provider event that focussed on how CSCI respond to concerns and complaints, she said this had been really useful in clarifying the role of the provider in complaint investigations. There have been no complaints made to the CSCI about this service in the last twelve months and the home has not received any complaints in the last twelve months. It was not clear that service users are always protected from the risk of abuse or harm. An initial protocol for aggressive behaviour is in place for one service user that includes signs of anxiety, some distraction techniques and use of as required medication (PRN), this has been written with the help of a health professional. However this individual has thrown a vase at another service user resulting in hospital treatment being needed. Police were called but Social Services were not informed under adult protection procedures. In light of such incidents the home will need to ensure they expand on the guidelines as they get to know this individual better, to detail the exact behaviours that could occur and how staff should respond ensuring the protection of service users. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 17 Daily records show one service user made an allegation of being inappropriately touched by another service user. This had not been reported to CSCI or Social Services under adult protection procedures. The Manager justified the non reporting by saying the service user had withdrawn the allegation two days later. Risk assessments for service users who have a history of allegation making need further development to protect both the service user and members of staff. Staff have received training in adult protection. Discussion with staff indicated they thought the adult protection training they had done had been very good as it had included lots of role play and really made them think about the issues. However the focus of training appears to have been on staff/carer abuse of service users. Service user on service user abuse was only briefly covered. Further thought should be given to providing staff with additional training on this. The Deputy Manager, at the beginning of the visit said that she was now aware of the importance of reporting of incidents and accidents under regulation 37 to the CSCI. She acknowledged that previously not all things had been reported that should have been and said that this would now be rectified. An incident of alleged abuse by one service user towards another occurred a few days after the key inspection visit. This was speedily notified to the CSCI and Social Services, and is being dealt with under adult protection guidelines. The records for the expenditure of service users monies were sampled. Some areas of practice were poor. Sampled receipts showed that when service users have been out as a group for a meal rather than working out what each individual has spent staff have just divided up the expenditure. This will result in some service users not contributing fully towards their meal whilst others are paying too much. Receipts also showed that service users had paid for staff meals and drinks, to include puddings for staff. This is not acceptable. Discussion with the Manager shows that the home does not have a policy in place guiding staff on the use of service users monies, one needs to be developed to ensure service users finances are fully safeguarded from the risk of abuse. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is generally high providing service users with an attractive and homely place to live. EVIDENCE: The home has undergone recent building works to provide all service users with a single bedroom, increase the number of en suite bathrooms and re-site the laundry. Work on additional en suite bathrooms is still in progress. The kitchen has been upgraded and a new office is in use. Décor throughout the home was observed to be in good order, the lounge and dining area had been redecorated since the last inspection. The carpet in the dining room had been refitted as required at the last inspection, this was now safe and looked nicer. However, when funds become available consideration should be given to an alternative flooring, of a type that is homely in style but easier to keep clean Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 19 Service users bedrooms were well decorated and personalised according to individual tastes and interests. One said he was looking forward to having his own en-suite bathroom, another said his room had been redecorated and confirmed he had chosen the new décor. Staff spoken with raised the issue of access to the external laundry being unsuitable, they feel uncomfortable going outside at night and it is not nice if it is cold or raining. At the last inspection the Manager said that planned improvements to the premises included a covered walkway to the outside laundry. This will provide a shelter for service users and staff when it is raining or snowing. No progress has been made towards this, the Manager said that several builders had looked at what was required but had commented it was a ‘tricky job’. The premises were clean, infection control measures were satisfactory to include hand washing facilities. The home had a visit from the Environmental Health Officer in January 2006, the findings were that the home had a good standard of hygiene. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff, who are appropriately qualified to meet their needs. Recruitment policy and practice supports and protects people living in the home. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. 75 of staff have achieved an NVQ, this exceeds the standard that at least 50 of staff have achieved this. The homes relatives questionnaire sampled included the comments ‘staff have a lot of time to give’, ‘staff very helpful’. Rotas and discussion with the Manager shows that the home does not use agency staff. The home generally has low level of staff sickness. It is good that the most of the staff have worked at the home for some time and therefore know the service users well. Rotas show that staffing levels generally meet service users needs. Usually there are two staff and the Manager and Deputy Manager on the early shift and three staff on the late shift. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 21 One staff spoken with commented that the Manager was intending to increase staffing levels at weekends so that more opportunities for activities could be provided. The Manager confirmed that he was intending to employ an additional staff at weekends. The recruitment records for three members of staff were sampled. These contained all the required evidence to show that a robust recruitment procedure had been followed to ensure that staff working with service users are suitable. Staff had generally received all the training they needed to enable them to meet service users needs. Staff are up to date with manual handling, food hygiene, first aid training. The staff training matrix did not evidence that all staff had completed training on managing violence and aggression. Most staff had done this in December 2005 but some staff missed out. The Manager will need to ensure additional training is arranged for those that need it. Staff spoken with said they had done Adult Protection training. Training specific to service user individual needs is also offered to include relationships, epilepsy and diabetes training. Several staff were booked on first aid refresher training the following week. A new member of staff spoken with confirmed they had completed a full induction to the home, they said that all the staff had been really helpful and supported them. Staff are generally well supported. Two staff were spoken with. They both felt very supported by the Manager and Deputy Manager and able to raise any concerns. Supervision is completed regularly by the Deputy Manager, often these sessions are also used to complete additional staff training. Recent topics covered include infection control, fire and record keeping. Annual appraisals are conducted to assess performance. Staff meetings do take place, the frequency of these could be increased, as there have been three meetings recorded since March 2006. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that service users benefit from a well run home. Service users can be confident that their views underpin all self-monitoring, review and development by the home. Arrangements are not always sufficient to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: The style of management in the home is relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living there. Staff meeting minutes show that staff are given feedback on the outcome of CSCI inspections. The Manager has a significant amount of experience in care and is a registered nurse, as well as having a NVQ 4 qualification. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 23 Systems are in place to assure quality. Service users have the opportunity to complete a questionnaire about their views of the home on an annual basis, questionnaires are also sent to relatives. The Deputy Manager said that a new comments book had also been implemented to seek the views of visitors to the home. The Manager has completed a development plan for the home, this would benefit from being dated and progress recorded. Staff have received record keeping training since the last inspection. This has been beneficial as service user records were observed to be much improved from the last inspection. Record of service users well being now being kept on a daily basis, entries were detailed with no inappropriate comments observed. Building work to the premises was underway to provide extra en –suite facilities. The partition walls had been built, some items of tools and materials were stored in the en-suites. There was no written risk assessment regarding the work in progress to ensure service user safety whilst the work was in progress. General risk assessments also required developing. Those in place needed review, for example the infection control assessment had not been reviewed since 2004. The homes fire records were observed, these indicated that regular testing of the alarms and emergency lighting is carried out. Certificates of servicing were available for the fire alarms. Records evidence that a recent fire drill had been conducted. It is an area of good practice that the home has completed individual risk assessments for evacuation in the event of a fire, these are reviewed after a drill has taken place. Staff have received refresher fire training. A letter received from the West Midlands Fire Service, dated May 2006 confirms fire precautions are satisfactory. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records of this showed that none were above the recommended safe temperature of 43 degrees centigrade. As previously stated in standard 23 of this report further work is needed to ensure service users are protected from harm by other service users who live at the home. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 2 X Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4) Requirement Ensure that all risks to service users (or others due to their behaviour) are appropriately assessed and detail level of risk and control measures in place. The Manager must ensure that all allegations of abuse or physical assaults on service users are dealt with under adult protection procedures to include notification to Social Services. The Manager must ensure that all reportable incidents as detailed in regulation 37 are notified to the CSCI without delay. Outstanding from previous inspection. Behaviour guidelines in light of recent incidents in the home must be expanded to ensure staff have detailed guidelines to follow for the protection of other service users. A full review of the use of service monies is needed to ensure individuals are not charged for expenditure by other service users or staff. A written policy and procedure on the use of service users monies DS0000004557.V319803.R01.S.doc Timescale for action 30/12/06 2. YA23 13(6) 30/11/06 3. YA23 37 13(6) 30/11/06 4. YA23 12(1) 13(6) 30/01/07 5. YA23 12(1) 13(6) 30/12/06 Mereside Version 5.2 Page 26 must be developed. 6. YA24 23(2) Access to the laundry must be reviewed and improved to ensure both staff and service users have both safe and comfortable access. The Manager must ensure that all staff have had training in managing challenging behaviour. The Manager must ensure risk assessments for the premises are up to date and cover all areas of risk to include ongoing building works. 30/06/07 7. YA35 18(1)(a) 30/01/07 8. YA42 13(4) 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA23 YA24 YA36 YA39 Good Practice Recommendations Staff should have further training on adult protection that focuses on service user to service user issues. Dining room. Consideration should be given to an alternative flooring, of a type that is homely in style but easier to keep clean. Increase the frequency of staff meetings. The development plan for the home should be dated and a record made of progress achieved toward individual goals. Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mereside DS0000004557.V319803.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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